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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842393
Report Date: 01/25/2023
Date Signed: 01/25/2023 10:44:28 AM

Document Has Been Signed on 01/25/2023 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PHILLIP M STOKOE HEAD STARTFACILITY NUMBER:
334842393
ADMINISTRATOR:BARBARA ESTHERFACILITY TYPE:
850
ADDRESS:4501 AMBS DRIVETELEPHONE:
(951) 826-4390
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 59TOTAL ENROLLED CHILDREN: 59CENSUS: 24DATE:
01/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ana Cano (Community Assistant )TIME COMPLETED:
10:45 AM
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On date and time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 01/06/2023. LPA met with, Community assistant, Ana Cano to discuss the purpose of this visit.

On 01/06/2023 Facility Staff self reported an incident where a child in care reported to their parent/guardian that a staff member had hurt their arm. UIR stated the parent/guardian of the child called the facility and spoke with management about this concern. The facility reported they would conduct an internal investigation into this matter.

LPA made unannounced visit to follow up on submission of this UIR on 01/12/2023. At time of visit LPA interviewed facility staff, the child involved and reviewed records/documents. Statements made from all staff interviewed denied the alleged incident had occurred. Staff noted that the day the incident was reported, the child was having a more difficult day than usual, and the parent/guardian was informed at pick up of the child’s behavioral concerns. LPA conducted an interview with the child in question but was unable to determine if the alleged incident had occurred or staff involved due to the child’s limited speech and participation in the interview process.

At time of this initial visit facility staff reached out to Program Coordinator via telephone. LPA was made aware the Program Coordinator was responsible for gathering statements from staff and parties involved during the Facility’s internal investigation. Program Coordinator was able to corroborate the same statements LPA received from staff during this interview process. The facility reached the conclusion that the incident its self was inconclusive do to conflicting information from the reporting party, staff statements and speaking with the child.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PHILLIP M STOKOE HEAD START
FACILITY NUMBER: 334842393
VISIT DATE: 01/25/2023
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Based on LPA observations and interview there appear to be no violations of Title 22. Although the alleged incident may have happened, or is valid, there is not a preponderance of evidence to prove the alleged incident did or did not occur.

An exit interview was conducted, LPA provided Community assistant, Ana Cano with a copy of this report and a notice of site visit on 01/25/2023.

Notice of site visit must be displayed for the next 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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